Doctors Say Getting Wired Too Costly, Time-Consuming

President Bush wanted widespread adoption of electronic health records by 2014, but that’s clearly not going to happen

John Carroll

When Barbara Walters, MD, senior medical director at the Dartmouth-Hitchcock group practice in New Hampshire, took center stage at a recent news conference to describe the effect that an electronic medical record system had on the practice, she was quick to praise the rewards that could be reaped when doctors have ready access to patient information.

Improved quality and better efficiency in handling diabetes cases was clear, she said, and the patient outreach efforts the technology enabled clearly brought down the number of hospitalizations and medical crises experienced by the group.

“Patients adore this service,” added Walters, whose practice was participating in a Medicare-sponsored demonstration program on EHRs. “They like getting calls from their doctor’s office.”

That’s all music to the ears of the champions of health care technology. Four years ago, President George W. Bush outlined a vision in which every American’s health record would be electronic by 2014.

Along the way the technology revolution would rein in costs, reduce the frequency of troubling medical errors, and ring in a new era of high quality medicine.

However, after years of endorsements and a string of bullish case studies, new research indicates that there is a yawning gap between the industry’s enthusiastic electronic pioneers and the majority of physicians working in small practices who still see no way around the big obstacles looming between themselves and the world of high-tech record keeping.

Surveying 2,758 doctors in late 2007 and early ’08, a research team at the Institute for Health Policy at Massachusetts General Hospital discovered that only 4 percent of physicians had a fully functional system that could satisfy some of the basic standards set by the Certification Commission for Healthcare Information Technology.

The study, which was supported by the Office of the National Coordinator for Health Information Technology (CCHIT)and was published in the New England Journal of Medicine, did find reason for optimism: 17 percent of doctors used some kind of EHR system, 16 percent had acquired a system but hadn’t booted it up yet, and 26 percent volunteered that they planned to buy one inside of two years.

The survey didn’t try to identify physicians who had fully CCHIT-certified systems because that would have excluded many physicians. Instead, it came up with a list of 17 functions that met their criteria for a fully functioning system.

“The physicians with these records were generally happy about them,” says Catherine M. DesRoches, DrPH, lead author of the NEJM article. “But this is a very small group. They’re the true believers, the early adopters.”

Bigger practices

They are also typically working in big practices that have the financial resources to size up the potential for an electronic health record and how it can pay for itself through improved efficiency. But once you move out of large urban areas and away from those large practices, says DesRoches, you find physicians on Main Street America who are much less likely to know others who have a system and don’t have the money to buy one or the time to implement it. Many fear getting stranded with obsolete, expensive technology.

DesRoches isn’t the only researcher to detect deep-seated skepticism among physicians.

Citing a shift by the Permanente Medical Group, the California HealthCare Foundation reported early this year that use of electronic health records in the state had risen to 37 percent of physicians. Yet even in California, 59 percent of physicians — primarily in smaller groups — say they still can’t afford a system of their own. Forty-two percent said they were leery of the cost of just maintaining a system.

“My own gut instinct is that as we get more widespread adoption without really good technical support, we’re going to have a lot of failures,” says DesRoches. “You need a lot of help to get it up to speed. In the absence of good technological support, I think we’ll see some abandonment of these systems.”

Some scary numbers

Mark Anderson, CEO of the AC Group, an IT consulting firm, put the tab for a certified EHR system at $35,000 to $50,000 per doctor over three years — a daunting figure for the nearly two thirds of the doctors in the NEJM survey who pinpointed the cost as their biggest hurdle.

But the problem, Anderson insists, isn’t really the cost of the hardware and software. He places the blame primarily on old systems in use that don’t meet CCHIT certification requirements as well as many that do meet the standards but aren’t being fully implemented.

“Our clients tell us it requires way too much change in the way physicians practice medicine today,” says the IT expert. “It slows them down, requiring them to enter a lot of information they never entered before. The average physician spends two minutes documenting a new patient and 38 seconds documenting a return patient because they dictate relatively quickly.

“Every patient is brand new when you go to an EMR, but in the average physician practice only 10 percent are actually new. Ninety percent are return. They go from a quick 38 seconds for the paper system to 4 to 5 minutes to document everything on the EMR, 50 patients a day.”

The problem is that vendors put the responsibility for entering the data on physicians. But if you get a combination of nurses and physician assistants as well as the patients doing the job, full adoption rates should rise. Add higher payments and bonuses for doctors who switch to a system that rewards physicians for keeping patients healthy rather than just treating them while sick and the country can make significant progress — or so the advocates of EMR systems say.

“If we don’t change the way we do things, we’ll get to 20 percent of doctors using the full EMR by 2014, moving from 4 percent,” says Anderson. “We could be at 80 percent by 2014, but we have to get back to reality. The vendors never discuss cost of data entry because they assume there is no cost.”

There’s no question that major obstacles remain, says Karen M. Bell, MD, director of the National Coordinator’s office of Health IT adoption, particularly for small physician practices. This is a profession where a 40-hour work week is practically unheard of, she notes, and asking a group of hard-pressed professionals to change the way they practice medicine is no easy task.

But payers of all stripes need to play a role here, she adds, including MCOs.

Managed care companies stand to benefit financially from the increased efficiency promised by these new systems, she notes, and they need to find ways to share that money with the physicians who are being asked to tackle the challenge.

“If Congress authorizes CMS to pay more to physicians, then we could see a good jump up,” says DesRoches. And she agrees that managed care has a role to play here as insurers roll out some pilot programs of their own.

This is one initiative that needs plenty of money to fuel adoption.

“At the current rate, we are clearly not going to get there,” says DesRoches about the Bush administration’s technology goal.